When Mehdi Variji fell ill with COVID-19 in early March, he holed up in his apartment in Tehran, Iran, to ride it out. The comforts of home didn’t seem to help. As he grew short of breath and oxygen levels in his blood ebbed, Variji, a 43-year-old physician who ran Tehran’s 21st District Clinic, knew he faced a bleak prognosis. “I’m taking three medicines, but they are not working on me,” he said in a cellphone video he shot a few days before his death.

A somber cellphone video shot on 20 March shows four gowned and masked workers preparing his grave in the courtyard of a shrine in his hometown, Sari. His wife and children stayed away because of the infection risk. It was just after midnight on Nowruz, the first day of the Persian new year and normally the beginning of a joyous festival.

Variji’s “strange and gloomy” burial drove home Iran’s plight to Seyed Naser Emadi, a friend of Variji’s and a dermatologist at Tehran University of Medical Sciences. No country’s medical ranks have been hit harder, perhaps, with 43 deaths tallied so far. “When we began to see a lot of our colleagues dying, we understood how bad the situation is,” Emadi says.

As of today, Iran has 38,309 confirmed cases and 2640 deaths—the highest totals in the Middle East. The latest model from scientists at the University of New South Wales predicts that by late June, Iran could see 48 million cases—more than half of its population—without major efforts to curb infections. Another simulation forecasts that, without dramatic interventions, Iran’s death toll could eventually eclipse 100,000.

Two peculiarities to Iran are undercutting its response. One, Iranian scientists say, is U.S.-led sanctions that cripple the country’s ability to import drugs and protective gear or produce them at home. “It’s medical terrorism imposed on Iranian civilians,” fumes Mohammad Kazem Jafari, president of the International Institute of Earthquake Engineering and Seismology in Tehran. The other is self-inflicted: Iranian media has been awash with dubious “cures” for COVID-19—hundreds of Iranians reportedly have died or become blind after consuming bootleg methanol—and rhetoric dismissing the outbreak as a Western plot. “It’s a high-stakes battle between science and conspiracy theories,” says Kaveh Madani, an Iran specialist at Yale University and formerly a senior environmental official in Iran.

Iran reported its first confirmed COVID-19 cases on 19 February: two fatalities in the holy city of Qom. Many observers suspect the virus had gained a foothold earlier, and its spread may have been accelerated by rallies across Iran on 11 February to mark the anniversary of the 1979 revolution that drew hundreds of thousands of people, then by parliamentary elections 10 days later. Iran’s Supreme Leader Ali Khamenei implored Iranians to come to the polls—the virus, he said, was being used as a pretext “to discourage people from voting.”

As the disease spread, Iran’s health ministry teamed up with the military and volunteers to equip and staff more than 1200 centers nationwide to screen for infected individuals, says Reza Malekzadeh, vice minister for research. But the government resisted imposing social distancing. President Hassan Rouhani on 25 February called the novel coronavirus “one of the enemy’s plots to bring our country into closure by spreading panic.”

Only on 17 March—by which time Iran had tallied 16,169 cases and 988 deaths—did the government shutter Qom’s shrines, which beckon pilgrims from across Iran and abroad. Universities nationwide have moved to online classes, major shopping malls have closed, and subway service in Isfahan and Shiraz is suspended. But government offices remain open with reduced staffs, and no regions have been placed under quarantine, though authorities are now attempting to curb intercity vehicle traffic.

Iran’s medical system was ill-prepared to handle the explosion of COVID-19 cases. A few charities have managed to ship a limited amount of medical supplies to Iran. But many Iranians blame shortages on sanctions the U.S. administration ratcheted up early last year after pulling out of the 2015 Iran nuclear deal. Those sanctions penalize non-U.S. companies for doing business with Iran and equate to “an almost total economic lockdown,” Amirhossein Takian of Tehran University of Medical Sciences and his colleagues write in a 17 March letter in The Lancet. “All aspects of prevention, diagnosis, and treatment are directly and indirectly hampered, and the country is falling short in combating the crisis.”

Some of Iran’s neighbors with frailer health care systems, fearing a spillover of infection, are calling on the United States to intervene. On 22 March, Pakistani Prime Minister Imran Khan appealed to the United States to lift the sanctions against Iran until the COVID-19 pandemic is over. The U.S. government’s response has been to impose additional sanctions. Late last month, however, the U.S. Department of State offered to provide Iran with humanitarian assistance and medical supplies.

Khamenei rejected the overture on 22 March. The United States was “accused of having created this virus,” he stated. “I do not know how accurate this assertion is. But, with the existence of such an accusation, which sane person can trust you?”

The next day, the government revoked permission it had given Doctors Without Borders to set up a 50-bed field hospital to treat COVID-19 patients in Isfahan. The treatment unit had just landed in Tehran and a nine-person team from the humanitarian organization had already arrived in Isfahan. Doctors Without Borders said it was “deeply surprised” by the decision, which came after the internet had been abuzz with wild rumors that their aim was to steal information about the genomes of COVID-19 viruses circulating in Iran.

The touchiness appears to be hindering efforts to gather information about the strains in Iran. “We do not know yet the differences between the Iran isolates and others from the Middle East and Asia,” as Iran has not deposited genomic sequences in the global GISAID platform, says Alfonso Rodríguez-Morales, an infectious disease specialist at the Technological University of Pereira.

The largest COVID-19 patient population in the Middle East does offer an opportunity to test potential therapies. Iran will participate in the World Health Organization’s global megatrial probing the effectiveness of four coronavirus treatments, including a drug combo used against HIV and the antimalarial drug chloroquine. Iranian scientists have launched at least a dozen other clinical trials, exploring the COVID-19 fighting promise of compounds such as tocilizumab, normally used to treat rheumatoid arthritis, and metformin, a diabetes medication. One team is infusing COVID-19 patients with antibody-rich blood of people who recovered fully from the illness. And a group led by Hossein Baharvand, director of the Royan Institute for Stem Cell Biology and Technology, is injecting mesenchymal stem cells into COVID-19 patients to test whether these cells’ ability to modulate the immune response and secrete antimicrobial peptides will help subdue the infection.

Iran is also trying a novel approach for killing cancer cells and microbes: cold atmospheric plasma (CAP). The ionized gas generates reactive oxygen and nitrogen molecules that disrupt cell membranes, and perhaps viral proteins. The technique has shown promise for decontaminating surfaces, says Michael Keidar, a plasma physicist and biomedical engineer at George Washington University who is developing a “plasma brush” to sterilize masks and other equipment used while treating COVID-19 patients. CAP has been attempted in only a handful of cancer patients, Keidar says. Applying it to COVID-19 patients, he says, is “very tricky and risky.” But Iranian scientists claim encouraging results. A team led by Jalaledin Ghanavi of the National Research Institute of Tuberculosis and Lung Disease has just completed a safety trial in 14 COVID-19 patients, half of whom received ionized helium administered via an anesthetic mask. The treated patients improved, says Ghanavi, who’s now enrolling subjects in a larger clinical trial.

Like so many of his colleagues on the COVID-19 frontline, Emadi fell ill with COVID-19. He had spent 1 week treating patients at Yas Hospital when, on 2 March, he experienced diffuse weakness and achiness, followed by a dry cough. “It felt like the flu,” he says. After he began to sweat and have chills, an x-ray revealed a “ground-glass” shadow in his lungs—the hallmark of COVID-19. He improved quickly.

Emadi worries that tens of thousands of aging Iranians who suffer from chronic lung ailments because of exposure to sulfur mustard, a chemical weapon used during the Iran-Iraq War, will not fare as well. He has treated many of these patients and fears they will be especially prone to severe symptoms that will land them in intensive care, and worse.

A few days ago, COVID-19 hit even closer to home for Emadi: On 25 March, his wife was rushed to intensive care with the disease. Beating the odds, she made a speedy recovery. He brought her home today.